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A  BUREAU 


OF 


CHILD   HYGIENE 


GO-OPERATIVE   STUDIES   AND   EXPERIMENTS 

BY 

THE  DEPARTMENT  OF  HEALTH 
OF  THE  CITY  OF  NEW  YORK 

AND 

THE  BUREAU  OF  MUNICIPAL  RESEARCH 


Questions  and  information  from  any  community  will  be  welcomed 
with  respect  to  the  two  subjects  dealt  with — the  medical  examination  of 
school  children  and  the  instruction  of  mothers  in  the  care  of  babies 


BUREAU    OF    MUNICIPAL    RESEARCH 

261     Broadway 

September,    1908 


CONTENTS 

PA 

Foreword  :    by  the  commissioner  of  health 

Introduction  :   bureau  of  child  hygiene 

Physical  examination  of  school  children 

Beginnings  in  New  York  City 

Beginnings 

Growth 

Notification  of  parents 

Progress  in  method 

Organization  and  supervision 9 

General  organization 

Supervision 

Corps  of  medical  inspectors 

Study  of  methods  and  results 11 

Period  covered 

Accuracy  of  examinations 

Treatment  provided 

An  experiment 15 

Plan  of  the  experimeut  £'' . 

Children   needing  treatment 

Treatment 

Conclusions 

Care  of  babies 27 

Reorganization  and  new  plans  . .    .  31 

parate  organization 

Standardizing  of  service 

A  follow-up  system 

Care  of  babies 

Other  activities 

libil  I        Forms  of  operative-  report  and   record  devised  for 
the  bureau  of  child  hygiene 

Fxhibit  11    Supplementary  tables 


//  r 


A  BUREAU 


OF 


CHILD    HYGIENE 


CO-OPERATIVE   STUDIES    AND    EXPERIMENTS 

BY 

THE  DEPARTMENT  OF  HEALTH 

OF  THE  CITY  OF  NEW  YORK 

AND 

THE  BUREAU  OF  MUNICIPAL  RESEARCH 


Questions  and  information  from  any  community  will  be  welcomed 
with  respect  to  the  two  subjects  dealt  with — the  medical  examination  of 
school  children  and  the  instruction  of  mothers  in  the  care  of  babies 


BUREAU     OF     MUNICIPAL     RESEARCH 

2  6l       B  ROADWAY 

September,    T908 


FOREWORD 

By  the  Commissioner  of  Health 

From  an  economic  as  well  as  a  humanitarian  point  of  view. 
there  can  be  no  more  valuable  service  rendered  to  humanity 
than  in  the  preservation  of  the  health  of  children.  In  the  pre- 
vention of  premature  death  and  the  promotion  of  normal  life, 
health  and  happiness,  no  work  can  be  of  greater  importance 
than  that  which  concerns  itself  vrith  children.  The  depart- 
ment of  health  has  long,  through  its  several  activities,  come 
into  close  and  intimate  contact  with  the  children  of  the  city. 
Owing,  however,  to  a  division  of  forces,  the  work  has  not 
proved  as  constructively  efficient  as  could  be  desired. 

A  series  of  investigations  has  shown  that  the  desired  end 
can  be  more  readily  reached  by  the  grouping  of  all  the  activi- 
ties relating  to  the  health  of  children  under  one  division  or 
bureau.  The  department  of  health  has  therefore  established  a 
bureau  of  child  hygiene,  a  step  which  I  look  upon  as  potentially 
one  of  the  most  important  in  the  history  of  preventive  medicine. 

The  object  of  medical  supervision  over  school  children  is 
two-fold :  first,  to  prevent  the  spread  of  contagious  diseases : 
second,  the  correction  of  physical  abnormalities,  effecting. 
among  its  important  results,  an  educational  economy  to  the 
state  by  placing  the  child  in  a  physical  condition  where  mental 
advancement  is  possible. 

The  manner  in  which  the  work  has  now  been  organized 
will  mean  a  saving  of  several  millions  of  dollars  annually  from 
the  standpoint  of  economy  alone,  to  say  nothing  of  the  im- 
measurable gain  in  the  health  of  the  children  of  this  city. 

THOMAS  DAELIXGTON.  M.  D, 


INTRODUCTION 

In  the  creation  of  a  division  of  child  hygiene,  the  depart- 
ment of  health  of  New  York  City  has  made  an  important  ad- 
dition to  the  program  of  preventive  medicine.  It  is  the  most 
comprehensive  plan  yet  put  into  operation  by  an  American 
city  to  promote  the  health  of  children  at  all  ages,  from  birth 
through  the  period  of  compulsory  school  attendance.  The  in- 
struction of  mothers  in  the  care  of  babies,  the  regulation  of 
midwifery,  the  regulation  of  the  conditions  under  which  babies 
may  be  boarded  out,  medical  supervision  of  school  children  for 
both  contagious  diseases  and  non-contagious  physical  defects 
and  the  physical  examination  of  children  applying  for  employ- 
ment permits,  are  the  principal  activities  now  outlined.  The 
methods  to  be  employed  are  mainly  educational, — the  educa- 
tion of  mothers  in  the  proper  feeding  and  care  of  children  in 
their  first  years,  the  education  of  parents  to  see  the  necessity 
for  healthful  home  conditions  and  for  medical  or  surgical 
treatment  of  physical  defects  when  reported  to  them  by  medi- 
cal inspectors  and  the  education  of  teachers  to  an  alert  ob- 
servation of  the  physical  needs  of  their  pupils.  The  depart- 
ment has  already  successfully  maintained  for  some  years  a 
hospital  and  dispensary  for  contagious  eye  diseases,  a  large 
proportion  of  whose  cases  are  school  children. 

The  possibilities  of  such  a  division,  progressively  and  ef- 
ficiently administered,  are  beyond  prophecy.  A  marked  re- 
duction in  infant  mortality,  a  higher  level  of  health  and  vital- 
ity among  children  who  live  and  greater  efficiency  of  the 
school  system  due  to  the  increased  ability  of  children  to  benefit 
by  their  instruction, — not  merely  the  application  of  remedies, 
but  the  discovery  of  the  causes  and  methods  of  prevention  of 
physical  defects  and  low  vitality, — these  direct  results  may 
reasonably  be  expected  and  demanded.  More  remote  and  less 
demonstrable  results  may  be  hoped  for  in  the  way  of  increased 
industrial  efficiency,  of  correspondingly  decreased  poverty  and 
dependency  and  of  decreased  truancy  and  delinquency  that 
now  too  often  lead  to  wasted  or  even  criminal  lives. 


The  establishmenl  of  the  division  of  child  hygiene*  fol- 
lowed upon  a  series  of  co-operative  studies  and  experiments  by 
the  department  of  health  and  the  Bureau  of  Municipal  Be- 
search.  A  study,  conducted  in  the  spring  of  1908,  of  the  pre- 
vailing methods  and  results  in  the  examination  of  school  chil- 
dren for  non-contagious  defects,  demonstrated  clearly  that  the 
accuracy  cf  the  examinations  was  open  to  serious  question,  and 
thai  no  adequate  methods  had  been  worked  out  for  securing 
the  treatment  of  children  discovered  to  be  defective.  Inspec- 
tors  examining  in  the  same  schools  rendered  reports  differing 
as  widely  as  by  100%  in  the  number  of  children  found  cle- 
t'eetive:  while  of  the  parents  notified  that  their  children  re- 
quired medical  attention  only  8%  reported  any  action.  It  was 
thus  made  evident  that  more  effective  methods  of  supervision 
and  of  follow-up  must  be  devised. 

To  determine  to  what  extent  action  on  the  part  of  parents 
could  he  obtained  by  personal  interview  and  explanation,  an 
experiment  in  three  schools  was  tried  covering  the  last  six 
week's  of  the  school  year  1907-1908.  The  parents  who  did  not 
respond  promptly  to  the  department's  customary  postal  notifi- 
cation  that  their  children  needed  treatment  were  interviewed 
either  at  school  or  at  home,  with  the  result  that  over  95% 
either  took  action  or  requested  the  department's  nurses  to  act 
for  them.  In  three  fourths  of  the  cases  only  one  interview  was 
necessary;  while  the  cost  in  nurse's  service  per  pupil  treated 
was  only  about  sixty  cents.  Even  this  figure  could  be  con- 
siderably  lowered  in  well-established  work. 

A  second  experiment,  during  the  summer  of  1908,  wTas 
concerned  with  the  care  of  babies.  Instead  of.  as  previously, 
a  large  cor]  s  of  inspectors  and  a  small  number  of  nurses  en- 
gaged  in  a  house  to  house  visitation  for  sick  children  under 
two  years  of  age,  the  department  of  health  employed  a  large 
staff  of  nurses  and  a  few  inspectors,  the  former  visiting  the 
homes  from  whieh  births  were  reported  and  instructing 
mothers  in  the  care  of  their  babies,  the  latter  visiting  sick 
babies  referred  by  nurses  or  others  and  conducting  educational 
lectures  and  instructions  in  vacation  schools,  playgrounds  and 
recreation  centres.  The  results  were  a  substantia]  improve- 
ment in  administrative  control  and  efficiency  and  a  strengthened 

•By  resolution  of  the  board  of  health.  August  19,  1008. 


conviction  that  the  problem  of  infant  mortality  is  funda- 
mentally educational  and  is  therefore  not  merely  a  summer 
problem  but  demands  an  all  the  year  round  service.  A  per- 
ceptible, though  on  the  whole  not  a  marked  decrease  in  the 
deaths  of  infants  occurred,  attributable  in  part  at  least  to 
the  summer  campaign  by  the  department  of  health  and  by 
many  public  and  private  agencies  in  alliance  with  it,  whose 
work  was  this  year  especially  active.  The  increased  activity 
of  the  department  of  health  during  the  last  few  years  in  in- 
specting the  milk  supply  may  also  have  contributed  to  the 
result. 

These  conclusions  were  held  sufficient  to  warrant  the  es- 
tablishment of  a  new  division  or  bureau.  Many  problems  re- 
lating to  the  health  of  children  of  course  remained  untouched 
by  the  experiments,  such  as  the  vexed  questions  of  free  meals 
and  free  eye-glasses  at  school  and  free  treatment  generally. 
These,  so  far  as  they  come  within  the  field  of  the  new  organiza- 
tion, are  for  it  to  solve  on  the  basis  of  its  experience. 

No  apology  is  offered  for  presenting  plans  and  purposes 
as  yet  unachieved.  As  plans  only,  they  may  prove  suggestive 
to  other  communities  facing  similar  problems.  But  more  im- 
portant than  that,  the  account  in  the  following  pages  describes, 
in  a  concrete  instance,  the  method  of  intelligent  self-criticism 
and  experiment  which  alone  enables  a  public  department  to 
keep  its  service  abreast  of  public  needs. 


PHYSICAL  EXAMINATION  OF  SCHOOL  CHILDREN 

Beginnings  in  New  York  City 

_     .     .  In   1903,  inspectors  of  the  department  of  health 

Beginnings 

examined  about  1,000  children  for  refractive  er- 
rors of  vision  and  for  orthopedic  defects.  Nearly  one  third 
were  found  to  have  spinal  curvature,  and  about  the  same  pro- 
portion to  have  defective  vision.  Additional  vision  tests  were 
made  in  the  autumn  of  1904,  some  12,000  children  being  ex- 
amined, of  whom  over  25%  were  reported  defective.  These 
results  indicated  clearly  enough  the  need  for  systematic  and 
thorough  physical  examination.  In  April,  1905,  therefore,  the 
department  of  health  extended  its  work,  examinations  being 
made  for  the  following  defects:  malnutrition,  diseased  anter- 
ior cervical  glands,  diseased  posterior  cervical  glands,  chorea, 
cardiac  disease,  pulmonary  disease,  skin  disease,  deformity  of 
spine,  deformity  of  chest,  deformity  of  extremities,  defective 
vision,  defective  hearing,  obstructed  nasal  breathing,  defective 
teeth,  deformed  palate,  hypertrophied  tonsils,  posterior  nasal 
growth  and  defective  mentality.  This  classification  remained 
with  few  changes  until  recently. 

During  1905.  some  55,000  children  were  examined,  of 
Growth 

whom  over  33,000  or  60.6%  were  pronounced  to  be  in 

need  of  treatment.  Each  year  since  1905,  an  increased  num- 
ber of  examinations  has  been  made,  as  may  be  seen  from  the 
following  table: 


Table  1 
PHYSICAL  EXAMINATIONS  OF  SCHOOL  CHILDREN 

1905 -June,  1908 

Borough                           1905                   1906            •         1907  1908  6  mos.  Total 

Manhattan    55,332      79,085       141,908  59,426  335,751 

Bronx    10,943  12,866  23,809 

Brooklyn    69,165  62,615  131,780 

Queens    

Richmond 438  26  464 


New  York  City.  .55,332      79,085      222,454     134,933      491,804 


DIAGRAM    I  -SHOWING   VARIATIONS     AMONG   MEDICAL   INSPECTORS  IN 
FINDING    PHYSICAL  DEFECTS 

MANHATTAN    -    ALL    SCHOOLS 


40 


50 


60 


PERCENTACE'Or  CHILDREN    EXAMINED  NEEDING  TREATMENT 


„,  ,.._      .  At  the  outset,  the  examinations  were  in  the  nature 

Notification  .  „  ... 

of  parents         rather  oi  an  investigation  than  a  branch  of  work 

intended  to  bring  about  practical  results  in  the 
way  of  treatment.  From  the  start,  however,  the  evidence  de- 
rived from  the  examinations  all  pointed  to  the  same  conclu- 
sion, viz.,  that  a  large  proportion  of  school  children  were  suf- 
fering- from  remediable  physical  defects.  It  immediately  be- 
came clear  that  examination  which  did  not  in  some  way  lead 
to  treatment  was  futile.  The  department  of  health  accord- 
ingly adopted  a  plan  for  notifying  the  parents  of  children  ex- 
amined in  regard  to  defects  needing  treatment.  At  first  the 
notification  was  enclosed  in  an  envelope  and  taken  home  by 
the  child.  Later,  a  reply  postal  card  was  employed,  the  reply 
being  intended  to  provide  the  physician  consulted  by  the 
parent  with  the  means  of  informing  the  department  of  health 
as  to  the  treatment  given.  This  method  has  been  used  up  to 
the  present  time. 

In  1907,  instead  of  recording  on  a  separate  card 
Progress  in  .  .         .  . 

method  each    examination    and   re-exammation,    a    single 

card  was  substituted  providing  space  for  the  rec- 
ord of  two  examinations  every  year  of  the  child's  school  life. 
These  cards  were  not  intended  to  be  forwarded  to  the  office  of 
the  department  of  health,  as  were  the  former  single  records. 
After  being  summarized  by  the  medical  inspector  for  the  pur- 
poses of  reporting,  they  were  left  in  the  schools,  usually  with 
the  individual  teachers.  The  intention  was  that  by  accompany- 
ing the  children  from  one  school  and  grade  to  another  they 
should  at  any  time  supply  teachers  with  information  as  to  the 
physical  condition  of  their  pupils.  These  are  the  only  innova- 
tions of  importance  since  1905. 


Organization  and  Supervision 


General 
organization 


The  medical  examination  of  school  children,  in- 
cluding that  for  non-contagious  defects,  has  al- 
ways been  a  part  of  the  work  carried  on  in  each 
borough  by  the  division  of  contagious  diseases,  under  the  chief 
medical  inspector.  Under  the  organization  hitherto  prevail- 
ing in  the  department  of  health,  these  officials  have  had  no 


direct  dealing  with  one  another.  Each  reported  to  the  assist- 
;mi  sanitary  superintendent  of  his  borough,  who  in  turn  was 
responsible  to  the  sanitary  superintendent  of  the  greater  city. 
The  only  means  of  unifying  the  practice  throughout  the  city 
has  thus  been  through  the  sanitary  superintendent,  who.  how- 
ever,  is  responsible  in  the  same  way  for  most  of  the  other 
activities  of  the  department.  The  organization  has  been  weak 
because  of  the"  lack  of  a  single  chief  official,  who  should  be  a 
specialist,  in  charge  of  the  work  throughout  the  city. 


In  Manhattan  an  attempt  was  made  to  develop 
Supervision  „  .   .  TT 

a  system  of  supervising  school  inspectors.     Here, 

during  the  past  year,  three  inspectors  were  assigned  to  exer- 
cise, subject  to  the  chief  medical  inspector,  supervision  over 
nearly  100  inspectors. The  trial  was  not  comprehensive  enough 
to  establish  any  conclusions.  It  is  unnecessary,  however,  to 
do  more  than  point  out  the  impossibility  of  adequate  admin- 
istrative control  over  a  larg'e  staff  of  medical  inspectors  with- 
out  supervising  inspectors  to  assist  the  chief  official. 


Until  1907,  the  medical  examination  of  school  chil- 
dren and  the  district  inspection  of  contagious  dis- 
eases were  performed  by  different  corps  of  inspec- 
tors. In  1907,  the  system  was  tried  of  combining 
all    work   in  the   same  staff,  each  inspector  performing  both 

scl 1  and  district  work.     In  Manhattan,  an  increased  number 

of  visits  followed;  but  reports  from  Brooklyn  were  not  favor- 
able.  On  the  whole,  the  experience  of  the  department  seems 
in  show  that  the  more  closely  the  examination  of  school  chil- 
dren is  allied  with  the  general  inspection  of  contagious  dis- 
eases,  the  more  likely  it  is  to  be  slighted  in  favor  of  the  latter. 
The  medjejil  supervision  of  school  children  has  now  come  to  be 
mainly  concerned  with  non-contagious  defects,  particularly  in 
their  bearing  upon  education.  This  is  a  distinct  type  of  work, 
and  requires  special  training  if  it  is  to  reach  a  maximum  of 
efficiency;  il  lias  as  much  claim  to  be  administered  through 
a  special  corps  as.  for  example,  the  administration  of  antitoxin. 

The  steps  necessary,  therefore,  to  a  proper  organization  of 
the  service  were: 

in 


DIAGRAM  2-  SHOWING    VARIATIONS   AMONGMEDICAL  INSPECTORS 
IN   FINDING  PHYSICAL  DEFECTS 

BROOKLYN    -     ALLSCHOOLS 


I 


PERCENTAGE    OF  CHILDREN  EXAMINED    NEEDING  TREATMENT 


(1)  The   separation  of  school  work  from  the  general   in- 

spection of  contagions  diseases,  and  its  performance 
by  a  separate  corps  of  inspectors. 

(2)  The   designation  or  appointment  of  a  single  chief  of- 

ficial, with  jurisdiction  over  the  entire  city,  and 
responsible  to  the  sanitary  superintendent  for  de- 
veloping and  putting  into  effect  a  constructive  policy 
and  for  co-ordinating  the  service  in  the  different 
boroughs. 

(3)  The  designation  of  a  certain  number  of  inspectors  to 

act  as  supervisors,  reporting  to  the  inspector  in 
charge  of  each  borough,  and  he  in  turn  to  the  chief 
of  the  division. 


Study  of  Methods  and  Results 

Early  in  1908,  a  study  of  the  prevailing  methods 

and  results  was  undertaken  by  the  Bureau   of 
methods  and  ...  .  .  . 

Municipal  .Research  in  co-operation  with  the  de- 
partment of  health.  The  inquiry  was  conducted 
by  the  Bureau,  while  the  department  of  health  assigned  inspec- 
tors and  nurses  as  required,  and  rendered  available  all  its  rec- 
ords and  reports.  The  plan  was  to  scrutinize  the  methods  em- 
ployed and  the  results  obtained,  with  a  view  to  devising  im- 
provements. For  this  purpose,  the  inquiry  concerned  itself 
first  with  the  accuracy  of  the  physical  examinations,  and  sec- 
ondly with  the  extent  of  the  treatment  actually  provided. 


results 


The  period  selected  for  special  study  was  the  latest 
Period 

■.      available — the  first  term  of  the  school  year  1907-08, 
covered  .  o  -i 

covering   approximately   the   interval   from   Sept.    1, 

1907  to  Jan.  31,  1908,  when  178,746  children  were  examined. 

If  physical  examinations  are  to  be  of  value,  they 
Accuracy  of  bg  accurately  made ;  they  must  neither  fail 

examinations 

to   find   defects  that   are   actually  present,   nor 

alarm  parents  unnecessarily  by  reporting  defects  which  do  not 

11 


exist  or  which  are  too  trivial  to  warrant  notice.  In  order  to 
I  Hove  the  work  of  the  department's  inspectors  in  this  respect, 
several  tests  were  applied.  For  the  two  largest  boroughs, 
Manhattan  and  Brooklyn,  a  chart  was  made  showing  for  the 
period  Sept.  1.  1007  to  Jan.  31,  1908,  the  total  examinations 
by  each  inspector  and  the  number  and  percentage  reported  by 
him  to  ho  defective.  The  results  showed  among  inspectors  a 
wide  variation  in  percentages  found  defective,  from  100%  to 
32',  in  Manhattan,  and  from  100%  to  18%  in  Brooklyn  (Dia- 
grams 1  and  2;  Supplementary  Tables  1  and  2).  Of  this  varia- 
tion a  part  was,  of  course,  attributable  to  actual  differences 
among  the  children  examined.  That  such  differences  could  be 
so  great,  however,  was  hardly  to  be  believed. 


The  next  step,  therefore,  was  to  select  certain  schools 
where  more  than  one  inspector  had  made  examinations  during 
the  period.  It  was  assumed  that  conditions  in  each  school  are 
nearly  uniform,  and  that  therefore  any  considerable  variations 
in  reports  must  be  due  to  variations  in  the  inspectors'  methods. 
A  chart  similar  to  the  former  was  drawn  (Diagram  3;  Supple- 
mentary Table  3),  from  which  it  appeared  that  discrepancies 
as  great  as  between  32%  and  92%  and  between  43%  and  84% 
occurred  in  the  same  schools.  In  other  words,  two  inspectors 
examining-  different  children  in  the  same  school  reported  re- 
sults differing  by  100%. 


Not  only  in  the  total  number  of  children  needing  treat- 
ment, hut  in  the  kind  of  defects  found  is  there  room  for  varia- 
tion, some  inspectors  tending  to  find  one  or  two  particular  de- 
fects, other  inspectors  to  find  oilier  defects.  To  discover  the 
extenl  to  which  this  might  be  the  case,  one  hundred  consecu- 
tive  eanls  were  taken  at  random  from  the  file  of  each  in- 
spector ami  a  chart  was  prepared  shoAving  for  each  inspector 
the  number  of  instances  reported  of  each  kind  of  defect  (Dia- 
gram l:  Supplementary  Table  4).  .As  may  he  observed,  some 
inspectors  found  a  few  instances  of  many  defects,  some  found 
many  instances  of  a  few  defects,  while  others  found  instances 
in  abundance  of  the  whole  list  of  defects. 

12 


DIAGRAM    3   -   SHOWING  VARIATIONS   AMD  N  G  M  EDICAL  INS  P  ECTQRS 

IN  the:  same  school  in  finding  physical  defects 

SELECTED   SCHOOLS-MANHATTAN   AND   BROOKLYN 


! 


PERCENTAGE  OF  CHILDREN  EXAMINEO  NEEDING   TREATMENT 


All  of  these  statements  were  based  on  the  regular  records 
of  the  department.  To  complete  the  case,  the  department  was 
requested  to  assign  special  inspectors  for  the  purpose  of  re-ex- 
amining children  who  had  first  been  examined  by  the  regular 
school  inspector.  The  work  of  15  inspectors  in  15  schools  was 
thus  tested,  an  average  of  20  children  being  re-examined  for 
each.  A  glance  at  the  following  columns  reveals  the  discrep- 
ancies already  mentioned,  with  one  additional — in  the  indi- 
viduals reported  defective,  even  when  the  number  so  reported 
was  nearly  in  agreement : 

Table  2 

VARIATIONS  AMONG  MEDICAL  INSPECTORS  IN 
FINDING  PHYSICAL  DEFECTS 

Re-examination  of  the  Same  Children 

Pound  by  Individuals  on 

Defects  Original  Special     whom  inspectors 

inspector  inspector         were  agreed 

Malnutrition    28  10  10 

Anaemia    22  11  7 

Enlarged  glands    119  126  84 

Nervous  disease  1  1  1 

Cardiac  disease    5  8  4 

Pulmonary  disease    13  2  2 

Skin  disease   10  7  3 

Orthopedic  defect   9  12  5 

Defective   vision    72  •  101  51 

Defective  hearing   6  9  2 

Defective   nasal   breathing.  .   34  20  15 

Defective  palate    22  16  14 

Defective  teeth    161  206  147 

Hypertrophied  tonsils    107  127  80 

Adenoids    70  96  49 

The  conclusion  was  therefore  unavoidable  that  physical 
examinations  as  conducted  have  been  far  from  uniform  and 
that  some  plan  must  be  devised  for  standardizing-  them.  It 
is  of  course  to  be  expected  that  diagnoses  will  disagree  to  some 
extent  even  in  the  face  of  effort  to  the  contrary;  but  this  dis- 
agreement must  be  confined  within  as  narrow  limits  as  possi- 
ble if  the  department's  reports  and  notifications  are  to  have 
a  reputation  for  reliability. 

13 


For  causing  treatment  to  be  provided  when  need- 
ed, the  department  has  relied,  as  has  already  been 
provided  '  '  J 

stated,  upon  a  postal  card  notification  to  parents. 
This  card  has  been  in  the  following  form: 

"The  parent  or  guardian  of is 

hereby  informed  that  a  physical  examination  of  this 
child  seems  to  show  an  abnormal  condition  of  the 

1 1 < •  I n ; 1 1  !:  I  :     

Take  this  card  to  your  family  physician  for  treat- 
ment and  advice." 

The  chief  evidence  as  to  the  extent  and  kind  of  the  treat- 
ment actually  provided  in  consequence  of  these  notifications 
is  afforded  by  the  replies  which  the  physicians  who  have  been 
consulted  are  requested  to  return  to  the  department  of  health. 
From  nearly  65,000  notifications  sent  between  Sept.  1,  1907, 
and  Jan.  31,  1908,  in  Manhattan  (where  the  system  had  been 
longest  in  operation)  about  5,500  replies  were  received,  or 
8.5%  of  the  possible  number;  in  Brooklyn,  of  53,000  notifica- 
tions,  7.6%   were   heard  from. 

.v  n  examination  was  made  of  over  1,500  replies  to  ascer- 
tain what  kind  of  information  they  present.  From  less  than 
5%  was  it  possible  to  determine  whether  operative  treatment 
was  act  rally  given  or  only  advised.  Similarly,  from  only  8% 
could  il  be  Learned  that  medical  treatment  was  actually  given. 

It  is  of  course  not  to  be  supposed  that  this  7%  or  8% 
represented  the  total  number  of  children  who  came  under  a 
i  hysician's  ••arc.  nor  that  only  13%  of  those  who  did  consult. 
;i  |  hysician  were  actually  treated.  It  is  clear,  however,  that 
the  method  prevailing  hitherto  is  one  which  leaves  tiie  depart- 
ment in  ignorance  of  results  as  to  over  90%  of  the  cases  dealt 
with. 

The  conclusions  of  the  study  were  therefore  (a)  that 
means  must  be  found  for  standardizing  the  physical  examina- 
tions, and  (b)  that  a  follow-up  system  must  be  devised  for 
securing  treatment  in  all  possible  cases. 

14 


DIAGRAM     4- SHOWING   VARIATIONS    AMONG   MEDICAL  INSPECTORS 
IN  THE  DEFECTS    FOUND 


percentage:  found, eachdefect* 
a _ — 


cai1;-)-Li,'-,-«>1"„=<  '—   o    «:    r    o  uj   —    •*•,. 

?  §  I Q  s  £  p;  s  ?  >  -  -       i"i^l52^|!^is 


5 < g 5 °  z £ E  G  > S g p  -  z S x < S"  g 5  p  =  h  |  ° s 

3u      S=  "feg  S  KSS5:  g  2"      S^"fe-S  gsS 


INSPECTOR  INSPECTOR 


JJi  Uil 


X  jJliLlJul 


^See  Supplementary  Table  4 


An  Experiment 

In   order  to  test  the   possibilities   of   a   thorough 
.  follow-up  system  based  upon  persuasion  and  per- 

experiment  sonal  interviews,  the  department  of  health  pro- 
vided for  an  experiment  covering  the  last  six 
weeks  of  the  school  year  1907-08.  Three  schools  were  chosen 
in  different  parts  of  Manhattan,  with  different  nationalities 
predominant.  To  each  was  assigned  an  inspector  and  a  nurse 
especially  selected  for  their  fitness.  Though  the  numbers  are 
not  large,  less  than  1,500  being  examined,  it  has  been  thought 
worth  while  to  present  in  considerable  detail  the  records  of  the 
experiment.  Where  numbers  are  too  small  to  warrant  con- 
clusions, they  may  serve  to  raise  questions.  Several  state- 
ments are  interesting  for  what  they  do  not  show.  Where 
statements  appear  inconclusive,  the  form  is  presented  as  one 
which  may  be  employed  when  more  data  are  available.  Each 
inspector  examined  about  15  children  a  day,  the  total  examined 
by  each  and  by  all  together  being  shown  in  the  following 
table : 


Table  3 

NUMBER  OF  CHILDREN  EXAMINED 
By  Schools 


School    number    and    location 


No.   141 

462    West    58th    St. 

No.   160 

Rivington    and    Suffolk    Sts. 

No.   168 

104th   and   105th    Sts.   near   2nd 
Ave. 

Total   number  examined 


Prevailing 
nationality 


Irish 
Jewish 

Italian 


Grades         in 
which   child- 
ren were  ex- 
amined 


2,3,4,5 
1,2,3 


Number 
examined 


468 
516 

45S 
1,442 


These  children  were  not  selected;  in  nearly  every  instance,  each 
class  was  completed  before  another  was  begun. 

15 


Children  were  found  to  need  treatment  as  follows: 
Children  ^    g^^    Nq     ^  gg% 

treatment  I"    School    No.    160  98% 

In  School  Xo.  168  92% 

The  percentages  are  startlingly  high.  How  far  these  children 
may  be  typical  of  the  school  children  of  the  city  is.  of  course, 
impossible  to  say.  It  is  sufficiently  serious,  however,  that  in 
any  three  schools  in  the  city,  from  88 cr  to  989c  of  nearly  1.500 
children  as  found  in  the  classes  are  declared  to  be  in  need  of 
treatment.  The  most  important  defects  needing  treatment 
were  those  of  vision  (42%),  nasal  breathing  (59%),  hyper- 
trophied  tonsils  (39%),  anaemia  (15%),  and  teeth  (73  %). 

The  reports  were  tabulated  in  the  form  shown  in  Diagram 
5.  in  order  to  disclose  any  divergences  that  might  exist  between 
the  sexes  or  between  grades,  ages,  or  normal  age  and  over-age 
children.  Owing  to  their  size,  the  tables  are  not  published ; 
detailed  information,  however,  will  be  gladly  furnished  on  re- 
quest. The  more  noticeable  points  are  presented  here.  School 
Xo.  160  was  reported  to  have  more  defective  children  and 
more  defects  per  child  than  the  others,  and  seems  to  show 
an  especially  high  number  of  enlarged  tonsils  (59.4%).  In 
Schools  Xo.  160  and  Xo.  168,  many  children  were  found  with 
defective  nasal  breathing  (71.3%  ;  75.7% )  and  defective  vision 
44.5%:  50.6%).  In  a  single  school.  Xo.  160.  there  appeared 
tu  be  a  considerable  difference  between  the  sexes  with  respect 
to  anaemia,  there  being  10%  among  the  boys  and  20%  among 
the  trirls:  in  all  schools  together,  the  figures  are  13%  for  boys 
and  18%  for  girls.  In  other  respects,  however,  there  appeared 
no  marked  preponderance  on  the  part  of  either  sex.  Taking 
into  consideration  all  defects,  there  seemed  to  be  a  slight  de- 
crease in  the  number  of  defects  in  the  older  children.  This 
may  have  been  partially  due  to  the  replacement  of  defective 
firsl  teeth  by  sound  permanent  teeth:  it  is  possible  also  that 
treatmenl  may  have  been  provided  for  the  older  children.  As 
for  grade,  defective  vision,  nasal  breathing  and  hypertrophied 
tonsils  were  slightly  more  frequent  in  the  lower  grades. 

A  tabulation  was  also  made  (Table  5)  of  normal  age  and 
over-age  children,  by  ages.  Contrary  to  expectation,  little 
difference  was  discovered  between  the  groups;  the  numbers. 
however,  are  too  small  to  yield  any  reliable  conclusions.     The 

16 


Table  4 


CHILDREN  EXAMINED  AND  FOUND  NEEDING 
TREATMENT 

Summary  by  School,  Age,  Grade,  Sex  and  Defects 


Defects 

needing 

School, 

age, 

Num- 

Needing 

treatment 

ber  ex- 

treatment 

Average 

grade. 

sex 

amined 

Total 

per  child 

needing 



No.  |    % 



treatment 

( 

School 

All    I 

All 

f  Both 

141 

468 

412 

ss.o 

879 

2.13 

ages  1 

grades 

|  sexes 

160 

516 

508 

984 

1469 

2.89 

l   168 

458 

425 

92.7 

1110 

2.61 

/   Age1 

!     6 

11 

11 

100.0 

31 

2.81 

i     7 

120 

115 

95.8 

334 

2.90 

(      All 

( 

\     8 

366 

350 

95.6 

946 

2.70 

All 

I  All 

\  Both 

)     9 

409 

385 

9i.l 

1009 

2.62 

schools 

)  grades 

j  sexes 

\    10 
11 

254 
142 

285 
132 

92.5 
92.9 

567 
311 

2.41 
2.35 

/    12 

81 

69 

85.1 

147 

2.13 

13 

•  40 

33 

82.5 

79 

2.39 

i     I4 

16 

12 

75.0 

31 

2.58 

15 

3 

3 

100.0 

q 

1.00 

.  Grade 

. 

I   1B 

71  • 

71 

100.0 

231 

3.25 

f 

\   2A 

261 

253 

96.9 

757 

2.99 

All 

I  All 

)  Both 

'   2B 

447 

418 

9S.5 

1076 

2.57 

< 

< 

\   3A 

410 

389 

918 

945 

2.42 

schools 

ages 

1  sexes 

)   3B 

137 

114 

8S.2 

242 

2.12 

^ 

( 

/   4A 

108  , 

92 

85.1 

194 

2.10 

1   5A 

8 

8 

100.0 

13 

1.62 

All 

(  All 

All 

(  Sex 

{ 

j  Males 

833 

784 

91 1 

2031 

2.59 

schools 

(  ages 

grades 

^Females 

609 

561 

92.1 

1427 

2.54 

Total 

1442 

1345 

93.2 

3458 

2.57 

1  At   last  birthday 


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form  of  analysis  is  offered  as  a  suggestion  to  others  pursuing 
this  line  of  inquiry. 

The  main  positive  fact  appearing  in  relation  to  defects  is 
that  from  88%  to  98%  of  the  children  examined  need  treat- 
ment, .1  conclusion  which  reinforces  the  already  urgent  de- 
mand  for  attention  1<>  the  physical  condition  of  school  children. 

The  uiaiii  object  of  the  experiment  was  to  dis- 
cover how  far  treatment  could  be  secured  through 
the  method  of  personal  persuasion  of  parents.  It  had  been 
asserted  that  a  large  number  of  parents  would  resent  inter- 
ference and  would  refuse  either  to  provide  treatment  or  to 
allow  it  to  be  provided.  This  view  was  not  shared  by  those 
directing  the  experiment;  they  believed  that  the  principal  ob- 
stacles to  be  overcome  were  ignorance  or  indifference,  and  that 
through  patient,  tactful  explanation  the  great  majority  of 
parents  could  be  made  to  see  the  reasonableness  of  treatment. 

The  general  methods  pursued  were  the  following.  The  in- 
spector continued  to  mail  to  parents  the  postal  card  notifica- 
tions as  previously,  at  the  same  time  giving  to  the  nurse  the 
record  of  the  physical  examination,  indicating  what  defects  re- 
quired  treatment.  Within  a  few  days,  she  either  visited  the 
borne  or  requested  the  parent  to  come  to  the  school  to  consult 
with  her.  At  this  interview,  having  the  child's  record  before 
her,  she  explained  the  nature  of  the  defects  from  which  the 
child  was  suffering  and  the  necessity  for  having  them  treated. 
She  Hi 'Mi  11  rged  the  parent  to  consult  the  family  physician; 
where  ther,e  was  none  and  the  family  claimed  to  be  unable  to 
pay  a  physician's  fee,  a  dispensary  was  suggested.  Where, 
owing  to  their  occupation,  the  parents  woe  unable  even  to 
take  their  children  to  a  dispensary,  the  nurse  obtained  from 
the  parent  a  written  requesl   to  take  the  children  herself. 

Tin-  belief  in  the  effectiveness  of  this  method  was  justified 
bj  the  result.  Only  4.2%  of  the  total  number  of  parents  re- 
fused to  act,  while  81  %  of  the  total  number  of  children  need- 
ing treatment  were  actually  treated  for  one  or  more  defects. 
Thai  the  lattei  figure  was  not  between  00%  and  05%  was  due 
to  the  lack  of  dispensary  facilities  available  to  school  No.  168. 
Table   6    shows    the    results    in    detail.     In    two    of  the   three 

20 


Table  6 


TREATMENT  PROVIDED 
Summary  by  Schools 


School 

number 

Total 

141 

160 

16S 

No. 

% 

Children   needing 

treatment 

41 

2 

508 

42 

1345 

100 

Children    treated 

371 

469 

255 

1095 

81.4 

For    all    defects 

22 

7 

385 

60 

672 

49.9 

For    one    or   more 

defects 

144 

S4 

195 

423 

31.5 

Children    not    treated 

41 

39 

170 

25C 

) 

18.6 

Pending 

34 

2 

157 

193 

14.4 

Refused 

1 

37 

13 

57 

4.2 

Defects   needing 

treatment 

879 

1469 

1110 

3458 

100 

Defects    treated 

581 

1222 

365 

2168 

62.6 

4-> 

IDs 

BB 

CD  03 
CD  0> 

■a 

<D 

03 
0 

!-. 

Eh 

0JJ§ 

CD   03 
CD   <0 

fcis 

■a 

Eh 

.a  a 

■a  +j 

0)  03 

H3 

a> 

03 

Eh 

+-> 
to  a 

•a  5 

CD    ™ 

a 

0) 
e3 
Sh 

Eh 

% 

Defective    vision 

144 

85 

230 

170 

.232 

31 

606 

286 

47.1 

Defective    hearing 

6 

3 

5 

11 

3 

— 

Defective    nasal 

breathing 

13S 

114 

368 

324 

347 

166 

853 

604 

70.8 

Hypertrophied    tonsils 

116 

94 

307 

264 

144 

72 

567 

430 

75.8 

Enlarged    glands 

3 

3 



Pulmonary    disease 

1 

2 

1 

3 

1 



Cardiac    disease 

12 

9 

22 

14 

2 

1 

36 

24 



Nervous  disease 

1 

1 

6 

7 

1 



Orthopedic    defect 

42 

22 

2 

5 

49 

22 



Anaemia 

77 

42 

71 

62 

75 

28 

223 

132 

59.2 

Malnutrition 

21 

11 

7 

7 

1 

29 

18 



Defective   teeth 

318 

200 

456 

381 

238 

66 

1062 

647 

60.9 

Defective    palate 

3 

6 

9 

— 

21 


schools,  over  90%  of  the  children  with  defects  received  treat- 
ment; in  one,  55%  were  treated  for  all  defects;  in  the  other, 
75%.  31%  in  all  schools  who  were  treated  for  one  or  more 
defects  were  at  the  close  of  the  experiment  still  awaiting 
treatment  for  other  defects.  Had  it  not  been  for  inadequate 
facilities  for  treatment,  the  greater  part  of  the  14%  pend- 
ing in  all  schools  could  have  been  treated,  and  the  31% 
partially  treated  could  have  been  completely  treated.  Supple- 
mentary analyses  of  various  aspects  of  the  experiment  were 
made,  but  are  not  of  sufficient  significance  to  warrant  publica- 
tion. Neither  age,  grade  nor  sex  was  distinguished  for  special 
ease  or  difficulty  as  to  securing  treatment.  Of  the  total 
children  treated,  two-thirds  of  the  medical  cases  came  under 
private  practitioners,  while  operative,  dental  and  eye  cases 
went  largely  to  institutions  (Table  7).  The  tendency  was  in 
dental  cases  to  extract  teeth  instead  of  to  fill  them  (Table  8). 
An  interesting  exception  to  this  practice  was  found  in  a  re- 
cently established  dental  clinic  for  one  of  the  schools  of  the 
Children's  Aid  Society,  where  many  of  the  children  in  School 
No.  141  were  treated.  In  this  school,  in  only  18%  of  the 
cases  cared  for  by  institutions  was  extraction  alone  employed. 

Proof  has  been  presented  that  treatment  can  be  secured 
by  the  method  of  personal  persuasion.  It  remains  to  show 
th  Mt  the  method  is  not  prohibited  by  the  amount  of  work  in- 
volved. Tables  9  and  10  supply  the  evidence.  Of  the  total 
children  whose  treatment  followed  in  consequence  of  per- 
sonal interviews,  about  three  fourths  (58% -79.9%)  required 
but  one  personal  interview,  and  the  average  visits  to  those 
treated  were  only  1.4.  The  net  average  result  of  a  day's 
work  by  a  nurse  was  the  actual  treatment  of  over  five  children, 
three  of  them  completely,  and  two  of  them  for  one  or  more 
defects.  In  other  words,  the  cost  in  nurses'  time  of  securing 
treatmenl  was  sixty  cents  per  child.  In  interpreting  these  con- 
clusions, il  must  be  borne  in  mind  that  the  experiment  faced 
the  difficulties  of  a  new  enterprise;  plans  had  to  be  explained 
and  arrangements  made;  much  time  was  consumed  in  waiting 
;it  the  dispensaries  which  would  have  been  turned  to  account 
if  facilities  had  been  adequate;  and  the  experiment  lasted 
hardly  long  enough  to  establish  a  routine  method  of  work-.  In 
spite  of  these   fads,  however,  it  has  been  demonstrated  that 

22 


Q 
H 
H 
<J 

& 
M 
«l 
H 

W 

CO 

O 

1-1 


X 

H 

<! 
O 

l-H 

W 

i* 

&, 
o 

Eh 
O 

PS 

W 
o 

a 


PS 
o 


■g-d 

o  o 


cd  o 


03 

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6* 

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43 

o 

4) 

> 

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Q 

CD  G 

a2 


>   c 
o 
CD 


cd  + 


■d 

a 

CD 

ti 

fcs 

<-, 

a 

<d 

CD 

;-. 

S- 

d 

~ 

bn 

a 

i3 

u 

^ 


-00  030,H<MCOTf*- 


aj  O 


gs 


eg 

03  O 
0Q«W 


iS 


cd  bfl 


CD  +-> 
CD  O 

a  a 


o  o 

CD  CD 

CD  CD 
■d-O 


CD  CD  * 

SS1 

d-d1' 

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+  oc 

e  c  g 

_hp_bp  ° 

'S3 'SiC 

CD 

CD    0   CO 

-CC  03 
eHchW 


Table  7 

KIND  OF  TREATMENT  PROVIDED :  PRIVATE  PRACTICE 
AND  INSTITUTIONS 


Kind  of 
treatment 


School 
number 


Medical 


Surgical 


Dental 


Ocular 


141 
160 
168 


Total 


141 
160 
168 


Total 


141 
160 

168 


Total 


141 
160 
168 


Total 


Chil- 
dren 
treated 


Treated   by- 


Private  physician, 
dentist   or  oculist 


No. 


%* 


70.2 
63.2 
70.9 
66.7 

3.7 
0.9 
0.7 
1.6 

36.0 
19.  i 
1S.1 


21.7 


Hospital,  dispen- 
sary     or      clinic 


No. 


36.8 
29.1 

33.3 

96.3 
99.1 
99.3 

9SJ, 

610 
80.6 
81.9 
75.6 

59.6 
73.3 
67.7 
71.6 


"Based  on  children  treated 


Table  8 

DENTAL  TREATMENT:  EXTRACTIONS  AND  FILLINGS 


Treated      by 

School 
number 

Total 

children 

given 

dental 

treatment 

Extractions 

Fillings 

Extractions 
and     fillings 

No. 

% 

No. 

% 

No. 

% 

Private   den-   \            }jl 
tist        or  ■{           {60 
physician      /            16° 

72 
74 
12 

158 

128 

307 

54 

489 

200 

381 

66 

C47 

21 
69 

12 

29.2 

93.2 

100.0 

616 

18.8 
99.7 

96.3 
78.2 

22.5 
98.5 
97.0 
718 

39 

4 

43~ 

94 
1 

2 

97~ 

133 

5 
2 

5Jt.2 
54 
0.0 

27.2 

73.J, 
0.3 
3.7 

19.8 

66.5 
1.3 

3.0 
21.6 

12 
1 

16.6 
14 

0.0 

I       Total 

^.                        (            141 
Dispensary     J            160 

or    clinic      )            168 

102 

24 

306 

52 

13 
10 

To- 

00 

1 

8.2 

7.8 
0.0 
0.0 

'        Total 

Total               )            JjjJ 
treated             "S           ^gg 

382 

45 

375 

64 

2.0 

11.0 
0.2 
0.0 

I.       Total 

484 

140 

3.6 

23 


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24 


Table  10 


AMOUNT  OF  WORK  BY  NURSES 


Children  requiring  attention  of 
nurse 

Children     treated     through     ef- 
forts   of   nurse 

Nurse  days   employed 

Average    children    given    atten- 
tion   per    nurse    day 

Average    children    treated    per 
nurse  day 

Home   visits 

Dispensary   visits 

School    visits 

Visits    of    all    kinds 
Average       total      visits      per 
nurse    day 

Average    total   visits    per    child 
treated 


School  number 


141 


412 


160 


168 


420 


Total 


132? 


371 

454 

250 

1075 

67 

60 

67 

194 

6.1 

S.2   • 

6.2 

6.8 

5.5 

7.5 

3.7 

5.5 

361 

3S1 

564 

1306 

29 

28 

33 

90 

34 

45 

31 

110 

424 

454 

628 

1506 

6.3 

7.5 

9.3 

7  7 

1.1 

1.6 

2.5 

1.4 

25 


treatment  can  be  secured  and  that  the  amount  of  work  or  ex- 
penditure involved  is  not  prohibitive. 

„       ,  The  conclusion  of  the  stud}^  and  experiment  de- 

Conclusions  .  ^  ^ 

scribed  in  the  foregoing  pages  may  be  summed 
up  in  a  few  words: 

(1)  The  examination  of  about  1,500  unselected  children,  of 

whom  from  88%  to  98%  were  declared  in  need  of 
treatment,  argues  that  the  necessity  for  medical 
supervision  of  school  children  is  more  serious  than 
has  been  supposed. 

(2)  The  obstacles  to   removing  physical   defects  are  not 

primarily  those  of  unwillingness  of  parents.  Per- 
sonal interviews  and  explanation  by  school  nurses 
obtained  action  or  permission  from  95%. 

(3)  The  cost  of  such  a  system  is  not  prohibitive.     Three- 

fourths  of  the  children,  whose  treatment  was  secured, 
required  but  one  interview;  the  cost  in  nurses'  salary 
was  sixty  cents  per  child  treated,  and  this  can  be 
reduced. 

(4)  The  most  difficult  problems  are  those  relating  to  ade- 

quacy of  facilities  for  treatment.  The  treatment  of 
children  involves  much  work  of  a  routine  nature 
which  has  no  particular  interest  for  the  average 
clinic  physician.  Whether  working  arrangements 
can  be  made  with  dispensaries  and  clinics  for  special 
attention  to  children  remains  to  be  seen.  The  dental 
care  of  school  children  has  as  yet  received  little  at- 
tention in  this  country.  With  a  single  exception,  the 
existing  clinics  provide  for  extraction,  but  for  little 
or  no  filling. 

Xo  nttempl  has  been  made  to  solve  the  question  of  ''free 
eye  glasses"  or  "free  meals".  Both  these  questions  require 
for  their  solution  more  data  than  have  yet  been  gathered.  To 
the  accessary  information,  the  experience  of  a,  staff  of  nurses 
in  intimate  contad  with  parents  and  homes  of  school  children 
should  yield  ;i  valuable  contribution. 

26 


After  Operation 


CARE  OF  BABIES 

For  many  years  the  department  of  health  has  maintained  a 
summer  corps  of  medical  inspectors  or  of  medical  inspectors  and 
nurses  for  the  purpose  of  diminishing  the  death  rate  of  infants 
from  diarrheal  diseases.  As  the  infant  death  rate  from  this 
cause  reaches  its  maximum  during  the  summer  months,  this 
work  has  been  limited  to  that  period.  The  method  pursued  in 
recent  years  has  been  to  employ  inspectors  and  nurses  in  a 
house  to  house  and  family  to  family  inquiry  for  sick  children 
under  two  years  of  age.  When  such  were  found,  and  there  was 
no  physician  in  attendance  on  the  case,  the  department  of 
health  physician  or  nurse,  gave  instruction  or  treatment,  revis- 
iting if  necessary.  In  this  way  a  considerable  portion  of  the 
tenement  sections  was  covered  once  during  the  summer. 

The  report  for  the  summer  of  1907  states  that  in  New  York 
City  175,272  families  were  visited,  in  which  44,130  children 
under  two  years  of  age  were  found.  Among  these,  1,783  cases 
of  diarrheal  disease  were  discovered,  of  which  688  were  at- 
tended by  the  department's  inspectors  or  nurses.  Revisits  were 
made  to  the  number  of  1,080.  From  this  account  it  appears  that 
on  the  average  4  families  were  visited  to  find  1  child ;  that  of  the 
children  found,  1  out  of  25  was  sick  at  the  time  of  visit;  and 
that  of  the  sick  children,  about  three-fifths  were  already  under 
the  care  of  a  private  physician.  The  net  result,  in  other  words, 
of  visiting  175,000  families  seems  to  have  been,  according  to 
the  report,  the  caring  for  some  700  sick  children,  each  being 
revisited  on  the  average  twice. 

It  is  manifestly  improbable,  however,  that  such  a  state- 
ment presents  a  fair  estimate  of  the  results  of  the  work  per- 
formed. The  circulars  of  instruction  distributed  year  after 
year  and  the  calls,  infrequent  though  they  were,  by  inspectors 
and  nurses  undoubtedly  had  some  influence  in  directing  the 
thought  of  mothers  to  the  proper  care  of  their  babies. 

Nevertheless  the  general  method  was  open  to  a  number  of 
serious  objections: 

(1)  The  condition  of  babies  undiscovered  was  entirely  un- 
known to  the  department,  the  inspector  or  nurse  being  solely 

27 


dependent  upon  the  chance  of  the  mothers'  being  at  home  at 
the  time  of  the  call. 

(2)  As  to  the  babies  who  were  found,  the  chances  were 
slight  that  the  single  visit  usually  paid  by  the  inspector  or 
nurse  during  the  summer  would  coincide  with  the  period  of 
sickness. 

(3)  The  limitation  of  the  department's  efforts  to  finding 
sick  babies  classed  its  work  as  mainly  remedial  rather  than 
preventive.  This  consideration  is  most  important  in  view  of 
the  frequently  sudden  onset  of  the  disease. 

(4)  The  administrative  control  over  inspectors  and  nurses 
by  the  central  office  was  much  lessened  by  the  latter 's  being 
obliged  to  accept  the  reports  of  the  former  as. to  children  found 
in  the  first  instance. 

(5)  In  employing  a  large  staff  of  inspectors  and  a  small 
staff  of  nurses  the  prevailing  plan  did  not  secure  the  greatest 
economy  of  expenditure.  Inspectors  receiving  $100  a  month 
for  two  or  three  hours  of  work  a  day  and  nurses  receiving  $75 
a  month  for  twice  that  time  were  expected  to  perform  practi- 
cally the  same  duties.  These  duties,  from  their  nature,  belong 
essentially  to  nurses. 

These  and  other  considerations  led  the  department  of 
health  to  adopt  a  new  plan  for  the  summer  of  1908.  A  larger 
staff  of  nurses  and  a  smaller  staff  of  inspectors  were  employed, 
the  former  for  the  routine  work  of  visitation,  the  latter  to 
care  for  sick  children  requiring  a  physician's  attention. 

To  each  nurse  Avas  furnished  the  reports  of  families  in  her 
district  in  which  births  had  recently  been  reported  to  the  bur- 
eau  of  records.  These  families  were  then  visited  for  the  pur- 
pose  of  instructing  the  mothers  in  proper  care  and  feeding,  no 
matter  whether  the  babies  were  sick-  or  well.     The  nurse  was 

expected  to  eontii her  visits  until  she  was  ready  to  report  a 

reasonable  assurance  thai  the  instructions  had  been  effective. 
Whoi  she  discovered  a  child  in  need  of  medical  care  and  not 
already  attended,  she  reported  it  to  the  department,  by  tele- 
phone if  necessary,  and  a  medical  inspector  was  sent.    Record 

28 


was  maintained  in  the  central  office  of  all  such  cases,  as  well 
as  of  cases  referred  by  nurses  to  dispensaries  or  to  other  agen- 
cies. Lectures  or  talks  of  instruction,  in  many  instances  ac- 
companied by  actual  demonstrations,  were  given  by  medical 
instructors  at  vacation  schools,  playgrounds  for  mothers  and 
children,  and  recreation  piers. 

A  noteworthy  feature  of  the  summer's  program  was  the 
effort  of  the  department  of  health  to  bring  together  in  a  single 
co-operative  scheme  all  the  agencies  working  to  diminish  in- 
fant sickness  and  mortality.  At  the  call  of  the  commissioner 
of  health,  early  in  the  summer,  representatives  of  the  depart- 
ment of  education  and  of  over  fifty  hospitals,  dispensaries  and 
charitable  agencies  met  and  organized  as  a  conference  on  the 
summer  care  of  babies,  with  several  working  committees.  In 
place  of  the  many  conflicting  circulars  of  instruction  previously 
distributed  by  various  organizations  in  the  city,  a  single  card, 
attractively  lithographed  and  simple  in  phraseology,  was  de- 
signed, and  issued  by  the  department  of  health.  Being  dis- 
tributed by  all  the  members  of  the  conference,  this  card  re- 
moved a  considerable  source  of  confusion  in  instructions. 
Plans  were  formulated  for  obviating  duplication  of  service. 
Principally  from  the  fact  that  the  staff  of  the  department  of 
health  was  inadequate  to  carry  out  its  program  to  the  full  ex- 
tent originally  contemplated,  such  duplication  was  not  encoun- 
tered to  any  considerable  degree.  A  foundation  was  laid, 
however,  for  a  closer  permanent  combination  of  forces. 

Full  reports  of  the  summer's  work  are  not  yet  available. 
The  present  returns  show  a  decrease  from  1907  of  two  hundred 
in  the  deaths  of  children  under  one  year  of  age  from  diar- 
rheal diseases.  To  what  extent  this  may  have  been  due  to 
the  summer  campaign,  to  a  better  milk  supply,  or  to  other 
influences,  it  is  difficult  to  say.  It  is  not  improbable  that  the 
increased  attention  given  to  the  health  of  babies  contributed  to 
the  result. 

The  summer 's  experience  established  the  conviction : 

(1)  That  the  methods  employed  should  be  mainly  preven- 
tive. 

29 


(2)  That  the  fundamental  preventive  measure  is  the  educa- 
tion of  mothers  in  the  proper  care  and  feeding  of  their  babies. 

(3)  That  an  educational  campaign,  to  be  fully  effective, 
must  not  be  limited  to  the  summer  months  but  must  continue 
the  year  round. 

(4)  That  the  method  of  visitation  pursued  not  only  pro- 
vides greater  administrative  control  but  presents  the  instruc- 
tion at  the  time  when  most  likely  to  be  effective,  i.  e.,  soon  af- 
ter the  birth  of  the  child. 

In  accordance  with  these  conclusions  the  department  of 
health  is  planning  to  incorporate,  as  soon  as  possible,  in  its 
regular  program  of  work  the  instruction  of  mothers  of  new- 
born babies. 


30 


REORGANIZATION  AND  NEW  PLANS 

Following  upon  the  foregoing  studies  and  experi- 
Separate  nients,  the  department  of  health  has  reorganized 

organization      its  service.    At  its  meeting  on  August  19th,  1908. 

the  board  of  health  voted  to  establish  a  division 
of  child  hygiene,  with  one  chief  official  for  the  entire  city. 
The  division  is  charged  not  only  with  the  medical  supervision 
of  school  children,  including  examination  for  both  contagious 
diseases  and  non-contagious  defects,  but  also  the  instruction  of 
mothers  in  the  care  of  new-born  infants,  the  regulation  of  mid- 
wifery, the  regulation  of  the  boarding  out  of  infants  and  the 
examination  of  children  for  employment  permits. 

The   service   of  medical   inspectors   and  nurses  in 

the  new  division  will  be  standardized  bv  control- 
ling of 
service  -^m§'  reeords  devised  and  already  installed  for  that 

purpose,  and  by  a  system  of  supervising  inspec- 
tors and  nurses.  From  the  records*,  the  official  in  charge  may 
see  how  many  examinations  each  inspector  is  making  daily 
and  how  many  defects  of  each  kind  he  is  finding.  Any  unusual 
variation  will  be  the  cause  for  investigation  by  a  supervisor. 
Supervisors  will  make  periodical  re-examinations  of  the  work 
of  each  inspector,  and  the  work  of  each  inspector  will  be 
charted  every  month  to  reveal  departures  from  uniformity. 
With  each  nurse,  an  account  is  kept  in  which  she  is  charged 
with  all  cases  reported  by  the  inspector  to  need  treatment, 
and  is  credited  with  all  cases  in  which  treatment  has  been 
provided.  From  this  record  the  chief  officer  may  read  as  often 
as  he  chooses  the  number  of  cases  outstanding  in  the  hands 
of  each  nurse  for  treatment.  If  this  number  increases  from 
week  to  week,  the  nurse  either  has  too  much  work  or  is  ineffi- 
cient :  if  it  decreases,  she  may  receive  additional  assignments. 
The  number  of  visits,  treatments  and  instructions  also  appears 
day  by  day,  so  that  the  amount  of  work  performed  is  at  once 
evident.  The  record  is  designed  to  systematize,  in  a  form 
to  facilitate  administrative  control,  the  reports  of  inspectors 
and  nurses. 

To  supplement  these,  a  form  of  report  of  supervising  in- 
spectors will  present  independent  evidence  from  the  field.     It 

*  See  Exhibit  1 

31 


will  also  be  the  business  of  the  supervising  inspectors  and 
nurses  to  educate  the  inspectors  and  nurses  to  a  higher  stand- 
ard of  professional  proficiency.  It  is  not  impossible  that  school 
inspection  may  assume  a  technical  interest,  similar  to  the 
service  in  clinics  which  confers  added  professional  standing. 

.  ,  ,.  Finallv,  to  secure  actual  treatment  in  as  many 

A  follow-up 

system  cases  as  possible,  the  follow-up  plan  of  the  ex- 

periment has  been  adopted.  Children  reported 
by  inspectors  as  needing  treatment  will  be  turned  over  to 
nurses,  who  will  employ  personal  interviews  with  parents  to 
urge  treatment.  No  children  once  pronounced  in  need  of  treat- 
ment will  be  overlooked. 

Similar  methods  will  be  applied  to  the  care  of  babies. 
Care  of 
.    ..  This  activity,  hitherto  limited  to  the  .summer  months, 

will    now,    if    provided    for    by    appropriation,    be 

maintained  the  year  round.     Each  nurse  will  receive  from  the 

department  office  a  record  of  the  families  in  her  district  in 

which  births  have  been  reported.     These  are  charged  to  her 

"case  account"  until  she  reports  upon  them.     She  is  expected 

to  visit  and  revisit  until  she  has  reason  to  believe  that  the 

mothers  have  learned  the  essentials   of  proper  care  of  their 

babies.     Sick  babies  are  referred  to  inspector's  when  necessary. 

Of  the  other  activities  included  in  the  plan  of  the 
Other                        . 

. .  ...         division,  i.  e.,  the  regulation  of  the  boarding  out  of 
activities                                                 P  ° 

babies,  the  regulation  of  midwifery  and  the  physical 
examination  of  children  applying  for  employment  certificates, 
the  first  is  the  only  one  in  which  more  than  a  beginning  has 
been  made.  A  permit  is  required  in  all  cases,  previous  to  the 
granting  of  which  the  home  is  inspected.  Reinspections  are 
made  at  intervals,  or  on  complaint;  permits  are  revoked  when 
rcuulal ions  arc  not  complied  with. 


32 


Exhibit  I 

FORMS  OF  OPERATIVE  REPORT  AND  RECORD  DEVISED 
FOR  THE   BUREAU   OF   CHILD  HYGIENE 

The  record-keeping  of  the  work  of  school  inspection  dur- 
ing the  second  quarter  of  1908  involved  the  provision  for  re- 
cording by  the  central  office  of  over  two  million  separate 
items,  and  of  a  much  greater  number  by  the  inspectors  and 
nurses  in  the  schools.  In  the  coming  year  the  work  of  record- 
keeping must  not  only  keep  pace  with  an  increased  field 
force,  but  will  be  complicated  by  a  demand  for  more  detailed 
statistics  of  the  results  of  physical  examinations. 

The  records  of  this  division  must  serve  a  two-fold  pur- 
pose. They  must  furnish  (1)  statistical  data,  and  (2)  data 
for  the  supervision  of  the  force  of  inspectors  and  nurses. 

In  form,  they  must  be  simple,  in  order  (1)  to  reduce  to 
a  minimum  the  clerical  work  of  inspectors  and  nurses,  and 
(2)  to  eliminate,  as  far  as  possible,  the  chance  of  error  both 
in  original  entry  and.  in  tabulation. 

The  following  report  and  record  forms  have  been  de- 
vised : 

Reports  from  the  field  staff 

Form  1 :  Physical  examination  record 
Form  2:  Inspector's  daily  report 
Form  3 :  School  index  card 
Form  4:  Nurse's  daily  report 
Office  records 

Form  5 :  Physical  examination  tabulation  sheet 
Form  6 :  Physical  examination  control  sheet 
Form  7 :  Contagious  diseases  tabulation  sheet 
Form  8:  Nurse's  control  and  tabulation  sheet 
Reports  from  the  tabulating  office 
For  supervision 

Form   9 :   Weekly   report    of  work   performed   by   in- 
spectors 
Form   10:    Weekly    report    of    work    performed    by 

nurses 
Form  11 :  Comparison  of  the  percentages  of  individ- 
ual defects  found  by  inspectors 

33 


For  statistics 
Form  12 :  Weekly  report  to  the  sanitary  superinten- 
dent of  the  department  of  health  and  to  the  city 
superintendent  of  schools.     The  same  form  is  used 
for  the  published  quarterly  report. 

Form  1     Physical  Examination  Record 

These  records  are  bound  in  book  form,  each  blank  being 
separated  by  perforation  into  four  cards,  indicated  for 
convenience  as  cards  1,  2,  3  and  4,  counting  from  left 
to  right.  In  order  that  the  department  of  education 
may  be  furnished  with  a  complete  physical  record  of 
each  child,  these  four  cards  form  two  pairs  of  dupli- 
cate records,  one  pair  dealing  with  examination,  the 
other  with  subsequent  treatment. 

On  cards  3  and  4  the  inspector  marks  with  crosses  on 
each  side  of  the  perforation  the  defects  found  that  need 
treatment.  On  card  3  he  makes  such  recommendations 
to  the  teacher  or  principal  as  will  enable  them  to  make 
the  proper  adjustment  of  seating,  exercise,  study,  etc. 

Cards  1  and  2  are  designed  for  the  nurse.  On  card  2  she 
finds  the  defects  by  their  code  number  and  such  re- 
marks as  the  inspector  thinks  necessary  for  her  guid- 
ance in  securing  treatment  for  the  child.  On  this  card 
also,  the  nurse  makes  the  record  of  her  efforts  to  secure 
treatment.  When  her  efforts  have  been  successful  or 
have'  met  with  absolute  refusal  of  the  parents  to  provide 
or  to  have  provided  the  proper  treatment,  she  takes 
the  child  to  the  inspector  for  re-examination  and  dis- 
charge. The  inspector's  signature  after  such  re-exam- 
ination relieves  the  nurse  of  further  responsibility. 

Card  1  is  made  out  by  the  nurse  only  after  she  has  se- 
cured treatment  for  the  child.  The  card  states  the  ac- 
tion  taken,  thus  supplementing  the  facts  recorded  on 
card  3. 

Card  4  is  torn  off  and  sent  to  the  department  of  health  by 
the  inspector  after  the  completion  of  the  examination. 
Card  3  is  given  by  the  nurse  to  the  principal.  Card  2 
is  senl   in  by  the  nurse  to  the  department  of  health  af- 

34 


•orm  1  Card  1       Oarrt  2 

Depamhent  of  Health  DEPARTMENT    OF   HEALTH 


DEPARTMENT    OF   HEALTH 


Card  4 

DEPARTMENT   OF   HEALTH 


Name 

Name 

Name 

Name 

School 

Class 

Address 

Address 

Born 

Date 

School 

Class 

Date 

School 

Date 

School 

Date 

For  School  Principal                                                             For  Department  of  Health                                                                       For  School  Principal 

For  Department  of  Health 

Defects                                              Defects                                                                                                        Recommendations 

Grade 

Grade 

Ke-ex 

Reos 

| 

j 

Remark^ 

Sex- 

Sex 

1. 

Age 

Age 

g* 

Remarks 

I  Defective  vision 

1    Dct'ci/tivi-  vision 

■2   hrlVudve  hi.-aring 

2  Defective  hearing 

.r{  DHVet,  Nasal  lni-iiUiitiL!- 

8  Defect.  Nasal  breathing 

School   consultations 

4  II \  ] .i'L'1  r.  .plii.-d  tmisiN 

■I   H\|"Ttr..|iluVil   tonsils 

Home  visits 

5  Tubercul.  lymph  nodes 

;'.  Tiilj.'ivtil    lymph  nodes 

Dispensary  visits 

C  I'Hliii'iiini'V  discast- 

0  Pulmonary  disease 

~  CiU-di;iL'   disi.'iifi1 

7  Cardiac  disease 

8  Chorea 

8  Chorea 

0  Orthopedic  defect 

'.)  Orthopedic  defect 

10  Malnutrition 

10  malnutrition 

• 

11  Defective  teeth 

11  Defective  teeth 

Date  discharged 

12  Defective  palate 

Itf  Defective  palate 

13  Height 

13  Height 

Inspector 

14  Weight 

14  Weight 

Nurse 

Inspector 

ns|icctur 

DEPARTMENT  OF  HEALTH,  CITY   OF  NEW  YORK 

SCHOOL  MEDICAL    INSPECTOR:     DAILY   REPORT 


o 

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Exclusions 

Ait. 

Cases 

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Exclusions 

Arr. 

Cases 

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Exclusions 

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Cases 

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Exclusions 

Cases 

Exclusions 

School 

NAME 

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AGE 

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Exclusions  from  School 

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DEPARTMENT  OF  HEALTH,  CITY  OF  NEW  YORK 


DATE 


SCHOOL  NURSE :    DAILY  REPORT 


TIME  OF 

Instructions 

Treatments 

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«™ 

Address 

Dis. 

Action  taken 

ter  the  completion  of  the  treatment  it  calls  for.  Card 
1  is  given  by  the  nurse  to  the  principal.  If  the  child 
is  found  to  have  no  defects,  cards  1  and  2  are  destroyed. 

Form  2     Inspector's  Daily  Report 

This  card  accounts  for  the  time  the  inspector  spends  in 
school,  the  number  of  examinations  he  makes,  the  cases 
of  contagious  diseases  he  finds  in  school  and  the  num- 
ber of  exclusions  for  such  diseases. 

On  the  back  of  the  card  are  recorded  the  names  and  ad- 
dresses of  excluded  and  absent  children  visited  by  the 
inspector. 

Form  3     School  Index  Card 

On  this  card  are  found  the  records  of  the  cases  of  eye  and 
skin  diseases  which  the  inspector  finds  in  his  examina- 
tions. These  cards  are  kept  in  the  schools,  arranged  by 
classes ;  on  them  the  nurse  finds  the  names  of  the  chil- 
dren whom  she  is  required  to  instruct  or  treat.  The 
card  calls  for  the  signature  of  the  inspector  to  show 
that  he  has  re-examined  the  children  reported  cured  by 
the  nurse. 

AVhen  all  cases  on  the  card  have  been  discharged  by  the 
inspector,  the  nurse  makes  a  summary  of  the  cases  at 
the  bottom  .of  the  card  and  sends  it  to  the  department 
of  health  for  tabulation. 

Form  4    Nurse's  Daily  Report 

This  card  accounts  for  the  time  the  nurse  spends  in 
school,  the  work  she  performs  there  and  the  number 
of  visits  made  to  parents  and  dispensaries. 

Form  5     Physical  Examination  Tabulation  Sheet 

On  this  sheet  are  recorded  the  physical  examinations  of 
each  inspector.  The  examination  cards  are  tabulated 
daily  under  the  following  age  groups :  under  8,  8-9, 
10-11,  12-13,  14  and  over;  differentiation  being  made 
for  sex.  The  designation  for  the  groups  made  on  the 
sheet  are:  M.  1,  2,  3,  4,  5 ;  F.  1,  2,  3,  4,  5. 

To  make  possible  rapid  and  accurate  tabulation,  pads  of 
a  convenient  size  have  been  designed,  ruled  like  the 
spaces  on  the  examination  card. 

35 


Form  6     Physical  Examination  Control  Sheet 

On  this  sheet  are  grouped  the  schools  that  form  the  dis- 
trict of  one  inspector.  By  noting  the  school  number  and 
name  of  the  nurse  or  nurses  working  with  inspectors, 
the  control  sheet  fixes  directly  the  responsibility  for 
work  performed.  At  the  end  of  any  desired  period,  the 
control  sheet  gives  for  each  school  the  number  of  chil- 
dren examined,  the  number  needing  treatment,  how 
many  have  been  treated,  how  many  are  still  pending 
and  who  is  responsible  for  these. 

Form  7      Contagious  Diseases  Tabulation  Sheet 

To  this  sheet  the  totals  on  the  inspector's  daily  report 
card  are  transferred.  By  placing  the  columns  of  the 
report  card  opposite  the  columns  on  the  sheet,  which  is 
ruled  in  the  same  way  as  the  report  card,  the  totals 
may  be  copied  on  the  sheet  directly,  thus  almost  en- 
tirely eliminating  the  possibility  of  error. 

A  daily  scrutiny  by  the  clerk  in  charge  detects  any  dan- 
ger centres,  as  shown  by  the  increased  number  of  cases 
reported  by  any  inspector.  To  discover  cases  unre- 
ported by  the  inspector,  comparison  will  be  made  with 
the  general  card  index  of  cases  reported  to  the  division 
of  contagious  diseases. 

Form  8     Nurse's  Control  and  Tabulation  Sheet 

By  the  method  described  in  connection  with  Form  7,  the 
daily  reports  of  the  nurses  are  tabulated  on  this  sheet. 
To  secure  control  over  the  number  of  cases  treated  and 
cured  because  of  the  nurse's  attention,  the  summaries 
of  the  school  index  cards  are  also  tabulated.  At  the  end 
of  the  school  term  or  at  any  time,  the  number  of  cases 
needing  treatment  as  shown  by  the  inspector's  conta- 
gious disease  sheet  can  be  compared  with  the  number 
of  cases  reported  cured. 

Forms  9  and  10    Weekly  Reports  of  Work  Performed  by  In- 
pectors  and  Nurses 

Forms  9  and  1()  are  designed  For  supervision  and  control 
over  the  inspectors  and  nurses.  They  are  in  the  form 
of  weekly  reports  made  ou1   by  the  clerk  in  charge  of 

36 


Form    ; 
PHYSICAL   EXAMINATIONS: 


TABULATION   SHEET 


Inspector 


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Form    6 

PHYSICAL    EXAMINATIONS: 

CONTROL    SHEET 


Inspector 


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CONTAGIOUS    DISEASES 


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NURSES'    CONTROL   AND    TABULATION    SHEET 


Inspector 


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Form   9 

WEEKLY   REPORT   OF   THE    WORK    OF    SCHOOL 

MEDICAL    INSPECTORS 


NAME   OF 
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WEEKLY   REPORT    OF    THE    WORK    OF    SCHOOL    NURSES 


Records   for   the  week 

Records  for   the   school  term 

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Form    11 

COMPARISON       OF       THE       PERCENTAGES      OF       THE       INDIVIDUAL 

DEFECTS   FOUND   BY  INSPECTORS   IN   PHYSICAL   EXAMINATIONS 


NAME    OF 

INSPEC 


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GENERAL     CONTAGIOUS     DISEASES:     EXCLUSIONS 


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Cases   found 

Cases    excluded 

Cases   reported   cured 

PHYSICAL    EXAMINATIONS   TOR   NON-CONTAGIOUS   DEFECTS 


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Number    of    inspectors 
Number   of  nurses    .  .  . 


tabulation  and  are  sent  to  the  chief  of  the  division,  to 
the  chief  inspector  of  each  borough  and  to  each  super- 
visor. 

The  names  of  the  inspectors  are  arranged  alphabetically 
under  their  supervisors ;  those  of  the  nurses,  under  the 
inspectors  with  whom   they  work. 

Form  11  Comparison  of  the  Percentages  of  Individual  De- 
fects Found  by  Inspectors 

Form  11  is  designed  to  show  the  individual  variations  of 
the  inspectors  in  finding  children  who  need  treatment, 
and  the  kind  of  defects.  Periodical  charts  like  Dia- 
grams 1-4,  based  upon  these  forms,  will  assist  the  super- 
vising officials  to  standardize  the  methods  of  physical 
examination. 

Form  12.  Weekly  Report  to  the  Sanitary  Superintendent  of 
the  Department  of  Health  and  to  the  City  Superintend- 
ent of  Schools 

This  form  gives  the  totals  for  each  borough  and  for  the 
whole  city.  It  also  serves  for  the  quarterly  statistical 
report  with  the  change  that  the  physical  examinations 
are  divided  into  the  age  and  sex  groups  given  on  Form  5. 
The  quarterly  statistical  reports  will  be  prefixed  with 
the  following  summary : 

Number  of  public  schools 
Kegistration 

Number   of  public   schools  under  inspection 
Registration 

Number  of  other  schools  under  inspection 
Registration 

Total  number  of  schools  under  inspection 
Registration 

Number  of  inspectors  on  duty  in  schools 

Number  of  nurses  on  duty  in  schools 

37 


Exhibit  2 
Supplementary  Table  1 

SHOWING  VARIATIONS  AMONG  MEDICAL  INSPECTORS 
IN  FINDING  PHYSICAL  DEFECTS  * 

Manhattan — All  Schools 


o 

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36 

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50 

670 

80.1 

99 

249 

66.3 

2 

418 

99.7 

51 

466 

80.0 

100 

760 

66.0 

3 

419 

97.6 

52 

456 

79.8 

101 

952 

65.9 

4 

731 

97.4 

53 

164 

79.7 

102 

570 

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310 

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79.4 

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245 

65.3 

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272 

95.9 

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630 

79.2 

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757 

65.1 

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592 

93.7 

56 

282 

78.3 

105 

968 

64.9 

8 

78 

93.6 

57 

702 

78.2 

106 

971 

64.5 

9 

821 

93.5 

58 

519 

78.2 

107 

555 

63.9 

10 

489 

93.2 

59 

649 

77.8 

108 

703 

63.8 

11 

343 

93.1 

60 

472 

77.5 

109 

735 

63.1 

12 

751 

92.6 

61 

1011 

77.5 

110 

631 

61.9 

13 

694 

92.5 

62 

772 

72.2 

111 

724 

61.8 

14 

498 

92.5 

63 

281 

77.2 

112 

400 

61.7 

15 

51- 

92.2 

64 

918 

77.0 

113 

842 

61.6 

16 

598 

91.9 

65 

361 

77.0 

114 

511 

61.4 

17 

336 

91.9 

66 

463 

76.5 

115 

718 

61.4 

18 

774 

91.6 

67 

570 

75.8 

116 

444 

61.0 

19 

753 

91.3 

68 

479 

75.3 

117 

691 

60.3 

20 

548 

90.5 

69 

462 

74.7 

118 

696 

60.0 

21 

1018 

S9.3 

70 

816 

74.7 

119 

708 

60.0 

22 

179 

88.2 

71 

1310 

74.4 

120 

495 

59.2 

23 

76S 

88.2 

72 

1034 

74.3 

121 

126 

58.7 

24 

302 

88.0 

73 

363 

74.1 

122 

895 

57.6 

25 

66 

87.9 

74 

S40 

73.8 

123 

864 

57.4 

26 

536 

86.9 

75 

770 

73.6 

124 

515 

57.0 

27 

1799 

86.9 

76 

364 

73.3 

125 

509 

56.5 

28 

765 

86.9 

77 

550 

72.5 

126 

114 

55.2 

29 

672 

86.6 

78 

1007 

72.2 

127 

352 

54.8 

30 

1149 

85.4 

79 

739 

71.7 

128 

872 

50.6 

31 

899 

85.2 

80 

552 

71.5 

129 

663 

50.0 

32 

857 

85.1 

81 

552 

71.0 

130 

618 

49.6 

33 

735 

84.9 

82 

S54 

70.7 

131 

665 

49.0 

34 

69S 

84.6 

83 

566 

70.6 

132 

783 

47.9 

35 

1000 

84.5 

84 

622 

70.5 

133 

682 

44.7 

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84.3 

85 

379 

70.4 

134 

466 

44.6 

37 

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84.2 

86 

929 

69.9 

135 

513 

43.7 

38 

493 

84.1 

87 

1094 

69.7 

136 

580 

43.6 

39 

362 

83.9 

88 

841 

69.6 

137 

544 

43.3 

4n 

208 

83.1 

89 

652 

68.7 

138 

763 

42.4 

41 

71", 

82.8 

90 

789 

68.7 

139 

795 

41.8 

42 

439 

82.7 

91 

377 

68.4 

140 

757 

40.7 

43 

171 

82.fi 

92 

981 

68.3 

141 

477 

40.2 

44 

815 

82.2 

93 

873 

67.8 

142 

15 

40.0 

1." 

882 

82.0 

94 

582 

67.7 

143 

119 

37.8 

if. 

828 

81.4 

95 

474 

67.1 

144 

914 

35.5 

47 

696 

81.0 

9fi 

935 

67.0 

145 

58 

32.7 

is 

613 

80.4 

97 

87  3 

66.7 

t'.t 

761 

98 

117 

66.6 

*   Total  children  examined  In  Manhattan,  Sept.  1,  1907 — Jan.  31,   1908;  see 

Diagram   I 
"•   An  arbitrary  Index  number  for  the  purposes  of  this  report;   the  same 

in  all   tables  and  diagrams 

38 


Supplementary  Table  2 

SHOWING  VARIATIONS  AMONG  MEDICAL  INSPECTORS 

IN  FINDING  PHYSICAL  DEFECTS  * 

Brooklyn — All  Schools 


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730 

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796 

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112 

63.4 

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734 

79.9 

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955 

62.5 

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365 

96.1 

37 

1251 

79.5 

68 

725 

62.3 

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845 

95.5 

38 

140 

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150 

61.4 

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651 

95.1 

39 

905 

79.1 

70 

2350 

61.2 

9 

1040 

94.7 

40 

1332 

78.4 

71 

909 

61.1 

10 

1174 

94.5 

41 

892 

78.0 

72 

907 

60.6 

11 

566 

92.7 

42 

269 

78.0 

73 

1009 

60.5 

12 

34 

91.2 

43 

1246 

77.7 

74 

552 

60.2 

13 

966 

90.3 

44 

2022 

77.3 

75 

1163 

60.1 

14 

279 

90.3 

45 

530 

77.2 

76 

409 

59.2 

15 

1815 

90.1 

46 

267 

76.7 

77 

846 

56.7 

16 

714 

90.0 

47 

392 

76.4 

78 

597 

55.9 

17 

1505 

90.0 

48 

194 

76.4 

79 

906 

53.7 

IS 

337 

89.0 

49 

309 

75.0 

80 

1079 

53.6 

19 

338 

87.8 

50 

907 

60.6 

81 

79 

53.2 

20 

1306 

87.4 

51 

985 

73.9 

82 

819 

52.2 

21 

1023 

87.0 

52 

1609 

73.8 

83 

2275 

50.9 

22 

120 

86.6 

53 

759 

71.5 

84 

432 

49.8 

23 

781 

86.5 

54 

763 

71.4 

85 

460 

47.6 

24 

658 

85.4 

55 

1254 

70.8 

86 

833 

47.2 

25 

1616 

83.3 

56 

786 

70.8 

87 

490 

42.2 

26 

150 

83.3 

57 

141 

70.2 

88 

1261 

40.4 

27 

702 

83.0 

58 

658 

69.8 

89 

505 

39.2 

28 

826 

82.8 

59 

368 

69.6 

90 

635 

33.4 

29 

776 

81.8 

60 

1757 

69.2 

91 

1458 

30.8 

30 

846 

81.4 

61 

960 

68.6 

92 

406 

24.4 

31 

1290 

81.2 

62 

210 

68.0 

93 

637 

18.4 

*   Total    children    examined  in   Brooklyn  Sept.    1,   1907-Jan.    31,    1908;    see 
Diagram    2 

**  An  arbitrary  index  number  for  the  purposes   of   this   report;   the  same 
in   all    tables    and   diagrams 

.     39 


Supplementary  Table  3 


SHOWING  VARIATIONS  AMONG  MEDICAL  INSPECTORS 
IN  FINDING  PHYSICAL  DEFECTS  * 

Manhattan  and  Brooklyn 


48 

134 

344 

43.9 

11 

89 

170 

37.0 

101 

262 

S4.3 

75 

210 

67.6 

141 

101 

456 

53.3 

56 

766 

70.6 

70 

154 

74.0 

79 

54 

763 

71.4 

24 

3  2 

75.0 

15 

295 

99.3 

131 

10S 

703 

63.5 

109 

74 

221 

49.4 

47 

111 

81.9 

S4 

432 

49. S 

10 

87 

109 

22.0 

52 

190 

68.9 

103 

42 

57.1 

63 

93 

545 

21.3 

54 

651 

79.3 

90 

30  . 

63.3 

64 

130 

536 

46.8 

57 

141 

70.2 

44 

196 

78.0 

139 

86 

833 

47.2 

142 

85 

124 

51.6 

S2 

109 

60.6 

41 

852 

77.6 

63 

299 

73. S 

23 

90 

605 

33.6 

98 

92 

329 

19.7 

41 

20 

95.0 

13 

"  7S 

96.2 

25 

192 

95.7 

6 

30 

100.0 

39 

20 

100.0 

*   Variations    among    medical     inspi  ctors     making    examinations    in    the 
same     school,     Sept.     1,     1907 — Jan.     31,     1908;     see    Diagram     3 
**   An  arbitrary  index  number  fur  the    purposes    of    this    report;    the    same 
in    all    tables   and    diagrams 


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BUREAU   OF  MUNICIPAL   RESEARCH 


i 


HISTORY 


January  1st,  1906    Organized  as  "Bureau  of  City  Betterment" 
May  3rd,  1907         Incorporated  as  "Bureau  of  Municipal  Research" 

PURPOSES 

To  promote  efficient  and  economical  municipal  government;  to  promote 
the  adoption  of  scientific  methods  of  accounting  and  of  reporting  the 
details  of  municipal  business,  with  a  view  to  facilitating  the  work  of 
public  officials;  to  secure  constructive  publicity  in  matters  pertaining  to 
municipal  problems ;  to  collect,  to  classify,  to  analyze,  to  correlate, 
to  interpret  and  to  publish  facts  as  to  the  administration  of  municipal 
government.     (Articles  of  Incorporation) 

REPORTS,  JANUARY,   1906  to    AUGUST,   1908 

Some  Phases  of  the  Work  of  the  Department  of  Street  Cleaning 

City  Owned  Houses 

Salary  Increases  Not  Provided  for  in  Budget 

Inefficiency  of  Inspection  of  Combustibles 

The  City  of  New  York,  the  Street  Railroad   Companies   and 

a  Million  and  a  Half  Dollars 
How  Manhattan  is  Governed 
Analysis   of   the    Salary   Expenditure   of   the    Department   of 

Health  of  the  City  of  New  York  for  the  Year  1906 
Making  a  Municipal  Budget ;  Functional  Accounts  and  Records 

for  the  Department  of  Health 
New  York  City's  Department  of  Finance 
The  Park  Question,   Part  II,  Critical  Study  and  Constructive 

Suggestions  Pertaining  to  Revenue    and   Deposits   of  the 

Department  of  Parks:  Manhattan  and  Richmond 
Memorandum  of  Matters  Relating  to  New  York  City's  Debt 

that  Suggest  the  Necessity  either  for  Judicial  Ruling   or 

for  Legislation 

REPORTS  IN   PROGRESS,   AUGUST,    1908 

The  Park  Question,  Part  I,  Critical  Study  and  Constructive 
Suggestions  Pertaining  to  Administrative  and  Accounting 
Methods  of  the  Department  of  Parks:  Manhattan  and 
Richmond 

Control  of  Water  Revenues 

Administration  of  Department  of  Water  Supply,  Gas  and 
Electricity 

Real  Estate  Transactions,  Department  of  Finance 

Tenement  House  Administration 

Bureau  of  Supplies  and  Repairs,  Department  of  Police 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 


DATE  BORROWED 


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I 


GAYLAMOUNT 

PAMPHLET  BINDER 

Manufactured  by 

;  GAYLORD  BROS.  Inc. 

Syracuse,  N.Y. 

Stockton,  Calif 


RA609 


N48 
1908 


New  York  (City)  Dept.  of  health. 
A  bureau  of  child  hygiene. 


JPR  2      1352 c  O.BlNy 


my 


1 


